Encourage good oral hygiene with regular sips of water before considering saliva replacement.

Therapeutic choice: Saliva replacement gel e.g. Biotène Oralbalance^® – use as required. See palliative care mouth care guidance at www.palliativecareguidelines.scot.nhs.uk.

Hyoscine butylbromide is first-line as it is a less sedating alternative to hyoscine hydrobromide.

Therapeutic choice:

• Hyoscine butylbromide SC bolus 20mg hourly as required (max 120mg/day) or SC infusion 60–120mg over 24 hours
• Glycopyrronium bromide SC bolus 200micrograms 6–8 hourly as required or SC infusion 600–1200micrograms over 24 hours
• Hyoscine hydrobromide (N.B. sedating) SC bolus 400micrograms every 2 hours as required (max 2000micrograms/day) or SC infusion 1200–2000micrograms over 24 hours

Assess for cause and reverse as appropriate.

Refer to palliative care guidelines and seek advice from local Palliative Care team for further advice.

Therapeutic choice:

• Midazolam (anxiety / distress) SC bolus 2mg–5mg hourly as required (max 6 doses in 24 hours) or SC infusion, initial starting dose 5mg, titrate up to 10–60mg over 24 hours.
• Haloperidol* (confusion / delirium) SC bolus 2mg once daily.
• Levomepromazine** (confusion / agitation) SC bolus 2.5mg–12.5mg in one to two divided doses.

*Haloperidol can prolong QT interval and contraindications include: patients with prolonged QTc interval and in combination with other drugs that prolong QT interval. Where possible modifiable risk factors for QT interval prolongation should be minimised e.g. discontinue other drugs known to prolong QT interval where possible. There may be certain circumstances when haloperidol may be used despite contraindications (e.g. distressed individual with an incurable condition at the end of life, limited or no reversible causes of agitation and distress). Seek senior advice before prescribing. A list of drugs that can prolong QT interval can be found at http://crediblemeds.org and further information can also be found in the Medicines Update Extra (MUE 08) Drug Induced Prolongation article available at www.ggcmedicines.org.uk. 

**Levomepromazine can cause sedation, hypotension and prolong QT interval. Use with caution.

Use guidelines to identify possible causes and suitable treatments (see www.palliativecareguidelines.scot.nhs.uk)

Prescribe regularly until symptoms controlled.

If vomiting regularly, switch to SC route, ideally administer via syringe pump over 24 hours.

Avoid pharmacologically antagonistic combinations e.g. cyclizine and metoclopramide.

Metoclopramide: use with caution in young, especially female patients, because of risk of extrapyramidal side effects.

In intractable nausea and vomiting, low dose levomepromazine is used as second line treatment. The 6mg tablet is an unlicensed preparation and may be available from your hospital pharmacy. Advice about its use should be obtained from the Palliative Care team.

Therapeutic options: refer to nausea and vomiting guidance at www.palliativecareguidelines.scot.nhs.uk.

Prophylactic antiemetics may be necessary (when opioid initiated and/or opioid dose increased):

Prescribe:

• Metoclopramide oral 10mg 6 hourly or
• Haloperidol oral 1.5mg at night

 N.B. Haloperidol and QT prolongation- refer to 'Restlessness' section above for guidance.